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Modifier 59 Clarification

CMS recently issued a clarification on existing policy regarding the use of modifier 59. A Medlearn Matters (MLN) article on the proper use of modifier “59” reduces this modifier’s applicability to ophthalmic procedures. CMS’ analysis of this modifier indicates that it has been misused, which may have prompted this clarification.

CPT defines modifier 59 as distinct procedural service

“Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier ‘59’ is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.”. . .

The clarification emphasizes appropriate use of the modifier. It should be used only if two procedures or services occur on the same day, by the same physician, involving a different session or patient encounter, procedure or surgery, site or organ system, or a separate incision/excision, lesion, or injury.

Of key importance in this article is the comment that different anatomic sites include different organs or different lesions in the same organ. It does NOT include treatment of contiguous structures of the same organ. It specifically states that treatment of posterior segment structures in the eye constitute a single anatomic site.

This modifier has always been one to monitor in your practice, and we expect further reduction in its use. You can access the MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/2007MMAN/list.asp#TopOfPage article number SE0715.

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